Abstract
Acute antibody-mediated rejection (AMR) remains a challenge after kidney transplantation (KT). As there is no clear-cut treatment recommendation, accurate information on current therapeutic strategies in real-life practice is needed. KT recipients from the multicenter Swiss Transplant Cohort Study treated for acute AMR during the first post-transplant year were included retrospectively. We aimed at describing the anti-rejection protocols used routinely, as well as patient and graft outcomes, with focus on infectious complications. Overall, 65/1669 (3.9%) KT recipients were treated for 75 episodes of acute AMR. In addition to corticosteroid boluses, most common therapies included plasmapheresis (56.0%), intravenous immunoglobulins (IVIg) (38.7%), rituximab (25.3%), and antithymocyte globulin (22.7%). At least one infectious complication occurred within 6 months from AMR treatment in 63.6% of patients. Plasmapheresis increased the risk of overall (hazard ratio [HR]: 2.89; P-value = 0.002) and opportunistic infection (HR: 5.32; P-value = 0.033). IVIg exerted a protective effect for bacterial infection (HR: 0.29; P-value = 0.053). The recovery of renal function was complete at 3 months after AMR treatment in 67% of episodes. One-year death-censored graft survival was 90.9%. Four patients (6.2%) died during the first year (two due to severe infection). In this nationwide cohort we found significant heterogeneity in therapeutic approaches for acute AMR. Infectious complications were common, particularly among KT recipients receiving plasmapheresis.
Highlights
Acute antibody-mediated rejection (AMR) is a potential cause of kidney allograft loss [1,2,3]
In 2009, the Kidney Disease Improving Global Outcomes (KDIGO) clinical guidelines recommended a number of treatment alternatives, with or without corticosteroids, including plasmapheresis, intravenous immunoglobulins (IVIg), anti-CD20 monoclonal antibody, and lymphocyte-depleting antibodies [5]
Among 1,669 STCS patients who underwent kidney transplantation (KT) between May 2008 and May 2014, we identified 65 recipients (3.9% [95% confidence interval (CI): 3.0–4.8]) with at least one treated episode of acute AMR within the first post-transplant year
Summary
Acute antibody-mediated rejection (AMR) is a potential cause of kidney allograft loss [1,2,3]. In 2009, the Kidney Disease Improving Global Outcomes (KDIGO) clinical guidelines recommended a number of treatment alternatives, with or without corticosteroids (grade 2C recommendations), including plasmapheresis, intravenous immunoglobulins (IVIg), anti-CD20 monoclonal antibody (mAb), and lymphocyte-depleting antibodies [5]. These recommendations were recently updated by The Transplantation Society Working Group, and the standard of care for acute active AMR remains plasmapheresis, IVIg (grade 2C) with corticosteroids (expert opinion), and adjunctive therapy in specific settings (grade 2B) [6]. Because of a limited number of patients and the heterogeneity in methodology, a detailed epidemiology of infection and its associated risk factors were not reported in these studies
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